Left main coronary artery compression in precapillary pulmonary hypertension.

Pulmonary hypertension (PH) is a progressive and invalidating condition despite available therapy. Addressing complications such as left main coronary artery compression (LMCo) due to the dilated pulmonary artery (PA) may improve symptoms and survival. Nevertheless, clear recommendations are lacking. The aim of this study is to analyze the prevalence, characteristics, predictive factors and impact of LMCo in a heterogenous precapillary PH population in a single referral center. Two hundred sixty-five adults with various etiologies of precapillary PH at catheterization were reviewed. Coronary angiography (CA) was performed for LMCo suspicion. Revascularization was performed in selected cases. Outcomes were assessed at a mean follow-up of 3.9 years. LMCo was suspected in 125 patients and confirmed in 39 (31.2%), of whom 21 (16.8%) had 50%-90% stenoses. Nine revascularizations were performed, with clinical improvement. The only periprocedural complication was a stent migration. LMCo was associated with PH etiology (p 0.003), occuring more frequently in congenital heart disease-associated PH (61.5% of all LMCo cases, 66.6% of LMCo ≥ 50%). Predictors of LMCo ≥50% were PA ≥ 37.5 mm (Sn 81%, Sp 74%) and PA-to-aorta ≥1.24 (Sn 81%, Sp 69%), with increased discrimination when considering RV end-diastolic area. LMCo ≥ 50% without revascularization presented clinical deterioration and worse survival (p 0.019). This analysis of a heterogeneous pre-capillary PH population provides LMCo prevalence estimation, predictive factors (PA size, PA-to-aorta, RV end-diastolic area and PH etiology) and long-term impact. While LMCo impact on survival is inconclusive, untreated LMCo ≥ 50% has worse prognosis. LMCo revascularization may be performed safely and with good outcomes.

Right ventricle to pulmonary artery coupling after transcatheter aortic valve implantation-Determinant factors and prognostic impact.

Introduction: Right ventricular (RV) dysfunction and pulmonary hypertension (PH) have been previously associated with unfavorable outcomes in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI), but little is known about the effect of right ventricle (RV) to pulmonary artery (PA) coupling. Our study aimed to evaluate the determinant factors and the prognostic value of RV-PA coupling in patients undergoing TAVI. Methods: One hundred sixty consecutive patients with severe AS were prospectively enrolled, between September 2018 and May 2020. They underwent a comprehensive echocardiogram before and 30 days after TAVI, including speckle tracking echocardiography (STE) for myocardial deformation analysis of the left ventricle (LV), left atrium (LA), and RV function. Complete data on myocardial deformation was available in 132 patients (76.6 ± 7.5 years, 52.5% men) who formed the final study population. The ratio of RV free wall longitudinal strain (RV-FWLS) to PA systolic pressure (PASP) was used as an estimate of RV-PA coupling. Patients were analyzed according to baseline RV-FWLS/PASP cut-off point, determined through time-dependent ROC curve analysis, as follows: normal RV-PA coupling group (RV-FWLS/PASP ≥0.63, n = 65) and impaired RV-PA coupling group (RV-FWLS/PASP < 0.63, n = 67). Results: A significant improvement of RV-PA coupling was observed early after TAVI (0.75 ± 0.3 vs. 0.64 ± 0.3 before TAVI, p < 0.001), mainly due to PASP decrease (p < 0.001). LA global longitudinal strain (LA-GLS) is an independent predictor of RV-PA coupling impairment before and after TAVI (OR = 0.837, p < 0.001, OR = 0.848, p < 0.001, respectively), while RV diameter is an independent predictor of persistent RV-PA coupling impairment after TAVI (OR = 1.174, p = 0.002). Impaired RV-PA coupling was associated with a worse survival rate (66.3% vs. 94.9%, p-value < 0.001) and emerged as an independent predictor of mortality (HR = 5.97, CI = 1.44-24.8, p = 0.014) and of the composite endpoint of death and rehospitalization (HR = 4.14, CI = 1.37-12.5, p = 0.012). Conclusion: Our results confirm that relief of aortic valve obstruction has beneficial effects on the baseline RV-PA coupling, and they occur early after TAVI. Despite significant improvement in LV, LA, and RV function after TAVI, RV-PA coupling remains impaired in some patients, it is mainly related to persistent pulmonary hypertension and is associated with adverse outcomes.

Unprotected Left Main Bifurcation Stenting in Acute Coronary Syndromes: Two-Stent Technique versus One-Stent Technique.

AIMS: There is little evidence guiding the choice between a one-stent and a two-stent approach in unprotected distal left main coronary artery disease (UDLMCAD) presenting as acute coronary syndrome (ACS). We aim to compare these two techniques in an unselected ACS group. METHODS AND RESULTS: We conducted a single center retrospective observational study, that included all patients with UDLMCAD and ACS undergoing PCI between 2014 and 2018. Group A underwent PCI with a one-stent technique (n = 41, 58.6%), Group B with a two-stent technique (n = 29, 41.4%). A total of 70 patients were included, with a median age of 63 years, including n = 12 (17.1%) with cardiogenic shock. There were no differences between Group A and B in terms of patient characteristics, including SYNTAX score (median 23). The 30-day mortality was 15.7% overall, and was lower in Group B (3.5% vs. 24.4%, p = 0.02). Mortality rate at 4 years was significantly lower in Group B (21.4% vs. 44%), also when adjusted in a multivariable regression model (HR 0.26, p = 0.01). CONCLUSIONS: In our study, patients with UDLMCAD and ACS undergoing PCI using a two-stent technique had lower early and midterm mortality compared to one-stent approach, even after adjusting for patient-related or angiographic factors.

Four-year outcomes after percutaneous coronary intervention of unprotected left main coronary artery disease in patients with stable angina and acute coronary syndrome.

Background. Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease (ULMCAD) have become a feasible and efficient alternative to coronary artery bypass surgery, especially in patients with acute coronary syndrome (ACS). There are limited data regarding early and late outcomes after ULMCAD PCI in patients with ACS and stable angina.The aim of this study was to compare early and four-year clinical outcomes in patients with ULMCAD PCI presenting as ACS or stable angina in a high-volume PCI center.Methods. We conducted a single center retrospective observational study, which included 146 patients with ULMCAD undergoing PCI between 2014 and 2018. Patients were divided in two groups: Group A included patients with stable angina (n = 70, 47.9%) and Group B patients with ACS (n = 76, 52.1%).Results. 30-day mortality was 8.22% overall, lower in Group A (1.43% vs 14.47%, p = 0.02). Mortality and major adverse cardiac events (MACE) rates at 4 years were significantly lower in Group A (9.64% vs 33.25%, p = 0.001, and 24.06% vs 40.11%, p = 0.012, respectively). Target lesion revascularization (TLR) at 4 year did not differ between groups (15% in Group A vs 12.76% in Group B, p = 0.5).Conclusions. In our study patients with ULMCAD and ACS undergoing PCI had higher early and long-term mortality and MACE rates compared to patients with stable angina, with similar TLR rate at 4-year follow-up.

Severe Aortic Stenosis and ATTRwt Amyloidosis - Beware in the Aging: A Case Report and Review of the Literature.

Degenerative aortic valve (AV) disease is the most frequent valvular heart disease slowly progressing to severe aortic stenosis (AS) which usually requires aortic valve replacement. Another frequent condition, especially among elderly people, is cardiac amyloidosis (CA), particularly the wild-type transthyretin cardiac amyloidosis (ATTRwt). Since both of these diseases are considered a marker of ageing, there is a significant proportion of elderly patients who associate both severe AS and CA. Recent studies reported a high prevalence of both severe AS and CA (AS-CA) in elderly patients referred for TAVR of 13-16%, carrying a worse prognosis. The present case illustrates the diagnostic algorithm and the management of ATTRwt CA in an elderly patient with severe paradoxical low-flow low-gradient AS, accompanied by a review of the current literature about the red flags which help identifying CA in patients with severe AS, as well as the prognosis and management of these disease association.

Systematic investment in the delivery of guideline-coherent therapy reduces mortality and overall costs in patients with ST-elevation myocardial infarction: Results from the Stent for Life economic model for Romania, Portugal, Basque Country and Kemerovo region.

AIMS: The Stent for Life initiative aims at the reduction of mortality in patients with ST-elevation myocardial infarction by enhancing timely access to primary percutaneous coronary intervention. To assess the associated health and socioeconomic impact, the Stent for Life economic project was launched and applied to four model regions: Romania, Portugal, the Basque Country in Spain, and the Kemerovo region in the Russian Federation. METHODS AND RESULTS: The Stent for Life economic model is based on a decision tree that incorporates primary percutaneous coronary intervention rates and mortality. Healthcare costs and indirect costs caused by loss of productivity were estimated. A baseline scenario simulating the status quo was compared to the Stent for Life scenario which integrated changes initiated by the Stent for Life programme. In the four model regions, primary percutaneous coronary intervention numbers rose substantially between 29-303%, while ST-elevation myocardial infarction mortality was reduced between 3-10%. Healthcare costs increased by 8% to 70%. Indirect cost savings ranged from 2-7%. Net societal costs were reduced in all model regions by 2-4%. CONCLUSION: The joint effort of the Stent for Life initiative and their local partners successfully saves lives. Moreover, the increase in healthcare costs was outweighed by indirect cost savings, leading to a net cost reduction in all four model regions. These findings demonstrate that systematic investments to improve the access of ST-elevation myocardial infarction patients to guideline-coherent therapy is beneficial, not only for the individual, but also for the society at large.

Echo-Doppler estimation of left ventricular filling pressure: results of the multicentre EACVI Euro-Filling study.

AIMS: The present Euro-Filling report aimed at comparing the diagnostic accuracy of the 2009 and 2016 echocardiographic grading algorithms for predicting invasively measured left ventricular filling pressure (LVFP). METHOD AND RESULTS: A total of 159 patients who underwent simultaneous evaluation of echo estimates of LVFP and invasive measurements of LV end-diastolic pressure (LVEDP) were enrolled at nine EACVI centres. Thirty-nine (25%) patients had a reduced LV ejection fraction (<50%), 77 (64%) were in NYHA ≥ II, and 85 (53%) had coronary artery disease. Sixty-four (40%) patients had elevated LVEDP (≥15 mmHg). Taken individually, all echocardiographic Doppler estimates of LVFP (E/A, E/e', left atrial volume, tricuspid regurgitation jet velocity) were marginally correlated with LVEDP. By using the 2016 recommendations, 65% of patients with normal non-invasive estimate of LVFP had normal LVEDP, while 79% of those with elevated non-invasive LVFP had elevated invasive LVEDP. By using 2009 recommendations, 68% of the patients with normal non-invasive LVFP had normal LVEDP, while 55% of those with elevated non-invasive LVFP had elevated LVEDP. The 2016 recommendations (sensitivity 75%, specificity 74%, positive predictive value 39%, negative predictive value 93%, AUC 0.78) identified slightly better patients with elevated invasive LVEDP (≥ 15 mmHg) as compared with the 2009 recommendations (sensitivity 43%, specificity 75%, positive predictive value 49%, negative predictive value 71%, AUC 0.68). CONCLUSION: The present Euro-Filling study demonstrates that the new 2016 recommendations for assessing LVFP non-invasively are fairly reliable and clinically useful, as well as superior to the 2009 recommendations in estimating invasive LVEDP.

Reperfusion therapy for ST elevation acute myocardial infarction 2010/2011: current status in 37 ESC countries.

AIMS: Primary percutaneous coronary intervention (PPCI) is the preferred reperfusion therapy in ST-elevation myocardial infarction (STEMI). We conducted this study to evaluate the contemporary status on the use and type of reperfusion therapy in patients admitted with STEMI in the European Society of Cardiology (ESC) member countries. METHODS AND RESULTS: A cross-sectional descriptive study based on aggregated country-level data on the use of reperfusion therapy in patients admitted with STEMI during 2010 or 2011. Thirty-seven ESC countries were able to provide data from existing national or regional registries. In countries where no such registries exist, data were based on best expert estimates. Data were collected on the use of STEMI reperfusion treatment and mortality, the numbers of cardiologists, and the availability of PPCI facilities in each country. Our survey provides a brief data summary of the degree of variation in reperfusion therapy across Europe. The number of PPCI procedures varied between countries, ranging from 23 to 884 per million inhabitants. Primary percutaneous coronary intervention and thrombolysis were the dominant reperfusion strategy in 33 and 4 countries, respectively. The mean population served by a single PPCI centre with a 24-h service 7 days a week ranged from 31 300 inhabitants per centre to 6 533 000 inhabitants per centre. Twenty-seven of the total 37 countries participated in a former survey from 2007, and major increases in PPCI utilization were observed in 13 of these countries. CONCLUSION: Large variations in reperfusion treatment are still present across Europe. Countries in Eastern and Southern Europe reported that a substantial number of STEMI patients are not receiving any reperfusion therapy. Implementation of the best reperfusion therapy as recommended in the guidelines should be encouraged.

Clinical and angiographic experience with a third-generation drug-eluting Orsiro stent in the treatment of single de novo coronary artery lesions (BIOFLOW-I): a prospective, first-in-man study.

AIMS: To report the four-month and nine-month angiographic results as well as one-year clinical follow-up from the first-in-man study with the silicon carbide and sirolimus-eluting bioabsorbable polymer (poly-L-lactic acid (PLLA) polymer) -coated cobalt-chromium Orsiro stent. METHODS AND RESULTS: A group of 30 patients with documented myocardial ischaemia related to a single de novo coronary stenosis up to 22 mm in length, in vessels with a 2.5 to 3.5 mm reference diameter, and between >50% and <90% diameter stenosis were enrolled at two sites. The primary endpoint of the study was in-stent late lumen loss at nine months. The secondary endpoints included major adverse cardiac events (MACE) at one year defined as the composite of cardiac death, ischaemia-driven target lesion revascularisation (TLR) and target vessel myocardial infarction (MI). Procedural success was 100%. Angiographic late lumen loss was 0.12±0.19 mm and 0.05±0.22 mm at four and nine months respectively. At one-year clinical follow-up, the composite MACE was 10% with one patient who died from cardiac death and two patients who had ischaemia-driven target lesion revascularisation. There was no report of MI or stent thrombosis. CONCLUSIONS: The Orsiro drug-eluting stent demonstrated potency with low rates of in-stent neointimal hyperplasia and cardiovascular events but warrants further evaluation in a larger population cohort with longer follow-up time points.

Impact of the Romanian national programme for interventional therapy in ST-elevation myocardial infarction.

A national programme for PPCI in STEMI patients was started in Romania in August 2010, based on an integrated and well-trained pre-hospital emergency medical system. Ten national centres experienced in PPCI were organised in a 24/7 system in five regional networks, in order to assist STEMI patients from areas offering PPCI within the first two hours after the first medical contact. For centres located further away, a strategy of local thrombolysis followed by transfer to the closest PCI centre was recommended. The total number of PPCI procedures increased from 1,289 in 2010 to 4,209 in 2011. The percentage of PPCI increased from 25.0% in 2010 to 49.32% in 2011. From 40 PPCI/million inhabitants in 2009, we reached 64/million in 2010 and 210/ million in 2011. In the Bucharest area there were 640 PPCI/ million in 2011. The global in-hospital mortality decreased from 13.5% in 2009 to 9.93% in 2011. In 2011 in-hospital mortality was 4.39%, 8.32% and 17.11% for PPCI, thrombolysis and no-reperfusion, respectively. In-hospital mortality was 7.28% in the PCI centres but 14.20% in centres without PCI facilities. The national programme for PPCI had a major impact on STEMI in-hospital mortality in Romania.

Implementation of primary angioplasty in Europe: stent for life initiative progress report.

AIMS: Primary percutaneous coronary intervention (PPCI) is the recommended treatment for patients with acute ST-segment elevation myocardial infarction (STEMI). Despite substantial evidence of its effectiveness, a 2007 study reported that only 40-45% of European STEMI patients were treated with PPCI, with large variations in treatment availability between countries. In 2008, the Stent for Life (SFL) initiative was launched by the European Association of Percutaneous Cardiovascular Interventions and EuroPCR in partnership with the European Society of Cardiology (ESC) Working Group on Acute Cardiac Care and country-specific national cardiac societies. The aim is to promote the prioritisation of percutaneous coronary intervention treatment towards those who will benefit most, namely STEMI patients. The following countries are currently participating: Bulgaria, Egypt, France, Greece, Italy, Portugal, Romania, Serbia, Spain and Turkey. METHODS AND RESULTS: Since SFL was launched, several activities have been initiated in the participating countries. Preliminary reports suggest that major increases have been seen in the numbers of PPCI performed, with some countries reporting very significant increases in PPCI use from 2008-2010. Improvements in STEMI mortality rates have also been observed. CONCLUSIONS: This report summarises the progress of the SFL initiative in the 10 target countries.

Atherothrombosis in 2 vascular territories in a young woman: importance of thrombophilia testing.

The diagnosis and management of complex and multiple inherited thrombophilias is still a challenge for the clinicians involved in this field, clinical events being the result of the interaction between genes, environmental or other acquired factors, and age. Moreover, various clinical manifestations as regards severity or type of event (venous or arterial thrombotic event, obstetrical complications) are cited in these patients. We present the case of a 20-year-old woman, with a 2-month history of third-generation contraceptive use and with recently diagnosed hypercholesterolemia, who presented ischemic events in 2 arterial territories: acute left lower limb ischemia and silent myocardial infarction. Screening tests for thrombophilia, including genetic testing, showed moderate hyperhomocysteinemia and 2 inherited thrombophilic defects. Invasive investigation of the coronary arteries showed the presence of advanced atherosclerotic disease. Management of this complex thrombophilia includes lifetime oral anticoagulation as well as a homocysteine-lowering strategy comprising lifestyle modification and group B (folic acid, B(6), B(12)) vitamin supplementing.

Left ventricular torsional dynamics in aortic stenosis: relationship between left ventricular untwisting and filling pressures. A two-dimensional speckle tracking study.

AIMS: The contribution of left ventricular (LV) untwisting to LV suction and early-diastolic filling was previously demonstrated, but this was not yet tested in patients with aortic stenosis (AS). We sought to assess the relationship between LV untwisting and LV filling pressures in patients with severe AS and normal left ventricular ejection fraction (LVEF) using speckle tracking echocardiography. METHODS AND RESULTS: Sixty-one consecutive patients (66 +/- 9 years) with severe AS, preserved LVEF (63 +/- 6%), and 40 normal subjects (47 +/- 12 years) were prospectively enrolled. A comprehensive echocardiographic examination was performed in all. LV rotation and twisting were assessed using speckle tracking echocardiography. Peak apical back rotation rate, peak LV untwisting rate, and time intervals from QRS onset (ECG) to each of them were measured. Brain natriuretic peptide (BNP) levels were determined in 30 patients. Patients with AS were older than normal subjects (P < 0.001). LV mass, LA volume, LV filling pressures as well as peak apical back rotation rate and time to peak apical back rotation rate were increased in patients (P < 0.05 for all). In patients with AS, both time to peak LV untwisting rate and time to peak apical back rotation rate were significantly related to E/E' ratio and to BNP levels (P < 0.04 for all). CONCLUSION: In patients with severe AS and preserved LVEF, there is a significant relationship between LV untwisting and LV filling pressures, suggesting a role for impaired LV untwisting in the pathophysiology of diastolic dysfunction in this setting.

Between Scylla and Charybdis: long-term cardiovascular complications after radiotherapy for Hodgkin's lymphoma.

Radiotherapy, an established treatment for local and regional control in neoplastic disease, may have several acute, subacute and chronic side effects. One of the main concerns about mediastinal radiotherapy is the occurrence of long-term cardiovascular complications after oncological treatment. This is an important issue--especially for thoracic neoplasms with long-term survival, such as breast cancer or Hodgkin's lymphoma--because of the increased cardiovascular morbidity and mortality. We present the case of a 50-year-old woman who developed several cardiovascular complications of radiotherapy more than 10 years after the successful treatment of Hodgkin's lymphoma, underlining the particular problems related to optimal therapeutic options in this population.

Left ventricular remodelling and torsional dynamics in dilated cardiomyopathy: reversed apical rotation as a marker of disease severity.

AIMS: Decreased left ventricular (LV) rotation and torsion and even reversed systolic apical rotation have been described in patients with dilated cardiomyopathy (DCM). We sought to test in patients with DCM whether reversed apical rotation with loss of LV torsion is related to the extent of LV remodelling and to the severity of LV dysfunction. METHODS AND RESULTS: Fifty consecutive patients with DCM (aged 49 +/- 13 years) were enrolled prospectively. Forty-seven healthy volunteers served as controls. All subjects underwent clinical examination, 12-lead electrocardiography, and a comprehensive echocardiogram. Basal and apical LV rotation and LV torsion were quantified by speckle tracking echocardiography. Left ventricular systolic rotation and torsion were reduced in patients, compared with controls (P < 0.001). Normally directed (counterclockwise) apical rotation was found in 24 patients (group 1), whereas 26 had reversed (clockwise) apical rotation (group 2). Patients in group 2 had larger LV volume, increased LV sphericity (P < or = 0.02), more severe systolic dysfunction (ejection fraction 26 +/- 7 vs. 33 +/- 12%), and higher filling pressures (E/E' ratio 19 +/- 10 vs. 14 +/- 6; P < 0.05). The main correlates of LV apical rotation were LV volume, sphericity index, and QRS duration. CONCLUSION: Reversed apical rotation and loss of LV torsion in patients with DCM is associated with significant LV remodelling, increased electrical dyssynchrony, reduced systolic function, and increased filling pressures, indicating a more advanced disease stage.

Pulmonary artery dilatation: an overlooked mechanism for angina pectoris.

Dilatation of the pulmonary artery may lead to the compression of adjacent structures. Of those, the extrinsic compression of the left main coronary artery is the most worrisome. We present the case of a 48-year-old woman who was diagnosed with pulmonary artery dilatation due to severe, thromboembolic pulmonary hypertension. She also had angina and coronary angiography revealed a 70% ostial stenosis of the left main coronary artery. The presence of this isolated lesion in a young woman without risk factors for atherosclerosis suggests extrinsic compression of the left main coronary artery by the dilated pulmonary artery as the likely mechanism. The patient underwent direct stenting of the left main coronary stenosis with a good result.

Remote-control percutaneous coronary interventions: concept, validation, and first-in-humans pilot clinical trial.

OBJECTIVES: This study was designed to assess the feasibility and safety of a Remote Navigation System (RNS, NaviCath, Haifa, Israel) in which the angioplasty guidewire, the balloon, and the stent are navigated via a computerized system. BACKGROUND: Percutaneous coronary interventions (PCIs) are manually performed under fluoroscopic guidance, requiring lead protection for the operators. A system in which the operator can remotely, safely, and precisely navigate the procedure during PCI would have clear advantages. METHODS: The RNS involves a computer-controlled wire and delivery system navigator. Following preclinical validation, the system was assessed in patients undergoing single-vessel PCI. RESULTS: The study involved 18 patients (age 55.9 years, 16% women). The RNS successfully crossed lesions with the guidewire in 17 patients. The stent was then advanced by the advance/rotate mode and adequately positioned in 15 of 17 cases. Technical malfunction was encountered in three patients in whom the procedure was successfully completed manually. Direct stenting was employed in 10 of 18 patients, pre-dilation in 7 patients, and after-stent balloon dilation in 5 patients. The total fluoroscopy time for 17 RNS patients was compared with the corresponding time of 20 consecutive patients who underwent standard single-lesion PCI. Fluoroscopy time was similar for both procedures, with 8.8 +/- 4.8 min with the RNS versus 9.1 +/- 3.5 min with the standard techniques (p = NS). Clinical success was 100% and technical success 94% for the guidewire and 83% for the overall procedure. CONCLUSIONS: The use of the RNS for guidewire, balloon, and stent manipulation during PCI appears safe and feasible for the treatment of patients with coronary stenosis. The system offers operator radiation safety and may enhance precision of stent placement and balloon dilation strategies.

Percutaneous coronary interventions in Europe 1992-2003.

AIMS: The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer revascularization approaches and its distribution in different regions in Europe. We report the data of the year 2003 and give an overview of the development of coronary interventions since 1992, when the first data collection was performed. METHODS AND RESULTS: Questionnaires were distributed yearly to delegates of all national societies of cardiology represented in the European Society of Cardiology to collect the case numbers of all local institutions and operators. The overall numbers of coronary angiographies increased from 1992 to 2003 from 684,000 to 1,993,000 (from 1,250 to 3,500 per million inhabitants). The respective numbers for percutaneous coronary interventions (PCI-coronary angioplasty) and coronary stenting procedures increased from 184,000 to 733,000 (from 335 to 1,300) and from 3,000 to 610,000 (from 5 to 1,100), respectively. Germany has been the most active country for the past years with 653,000 angiographies (7,800), 222,000 angioplasties (2,500), and 180,000 stenting procedures (2,200) in 2003. The indication has shifted towards acute coronary syndromes, as demonstrated by raising rates of interventions for acute myocardial infarction over the last decade. The procedures are more readily performed and safer, as shown by increasing rate of "ad hoc" PCI and decreasing need for emergency coronary artery bypass surgery (CABG). In 2003, use of drug-eluting stents had further increased. However, an enormous variability is reported with the highest rate in Portugal (55%). CONCLUSION: Interventional cardiology in Europe is still expanding, mainly but not exclusively due to rapid growth in the eastern European countries. A number of new coronary revascularization procedures introduced over the years have all but disappeared. Only stenting has experienced an exponential growth. The same can be forecast for drug-eluting stenting.

Anterolateral papillary muscle rupture: diagnosis and successful treatment (a case report).

We report the case of a young man presenting with chest pain, dyspnea, and syncope in whom transthoracic and transesophageal echocardiography helped to diagnose anterolateral papillary muscle rupture. After cardiac catheterization (which confirmed the severe mitral regurgitation and showed two vessel coronary disease), mitral valve replacement was performed together with coronary bypass grafting.